How the Spanish flu changed the world

From the World Economic Forum:

A couple of years ago, journalist Laura Spinney could hardly believe how little people thought about the Spanish flu pandemic, which swept the globe in three deadly waves between 1918 and 1919.

So she wrote a book – Pale Rider: The Spanish Flu of 1918 and How It Changed the World – to bring the tragedy that claimed 50 million lives back into our consciousness,

. . . .

“It seemed to me there was this huge hole in our collective memory about the worst disaster of the 20th Century. It’s definitely not remembered in the same way as the two world wars – there is some different way we remember pandemics.

One of the ways I tried to explain it in my book was that, to me, that pandemic is remembered individually as millions of discrete tragedies, not in a history book sense of something that happened collectively to humanity.”

. . . .

We think it infected about 500 million people – so one in three people in the world alive at that time, and it killed 50 million of them. The death toll could have been even higher because there was a big problem with under-reporting at the time. They didn’t have a reliable diagnostic test.

. . . .

Pandemic flu is much worse than seasonal flu, and we think there have been 15 flu pandemics in the past 500 years. Every seasonal flu started out as a pandemic flu, which was much more virulent because it was new in the human population. Gradually over time, it evolved to become more benign and to live in a more harmonious relationship with humanity.

There are lots of theories for why the Spanish flu was so virulent and they’re not mutually exclusive. Some of them have to do with the inherent biology of that virus, and some of them with the state of the world at the time. That pandemic obviously emerged when the world was at war; there were extraordinary circumstances. Lots of people were on the move, not only troops, but also civilians: refugees and displaced persons. And there was a lot of hunger.

All of these factors may have fed into the virulence of the virus. There was definitely something very abnormal about 1918. If you think about the five flu pandemics we’ve had since the 1890s, none of them has killed more than about 4 million people maximum, whereas we think Spanish flu killed 50 million.

. . . .

There were no commercial aeroplanes, so the fastest way you could get around was by ship or by train. Henry Ford had invented his Model T motor car, but they were still the preserve of the rich, as were telephones. And illiteracy was much higher than it is now, which had an impact because the main way that news was transmitted was by newspapers. In illiterate populations news travelled much more slowly and was often distorted.

. . . .

In the short term, there was a jump in life expectancy, because a lot of people who were very ill with, for example, TB, which was a massive killer at that time, were purged from the population. They were probably the first to die of the Spanish flu because they were already in a weakened state. The people who were ill died and the people who were left behind were healthier.

There was also a baby boom in the 1920s, which has always been put down to the war and the men returning from the front. But there is an argument that the flu could have contributed because it left behind a smaller, healthier population that was able to reproduce in higher numbers. Norway, for example, had a baby boom even though it was neutral in the war.

Among those very vulnerable to the Spanish flu were the 20 to 40-year-olds. Normally flu is most dangerous to young children and to the very old, but in 1918, bizarrely, it was this middle age group. There wasn’t much of a social welfare net, even in wealthy countries, so lots of dependents were left without any means of support because the breadwinners were taken out by the flu.

. . . .

One of the great tragedies of 1918 is that those dependents just vanish into the cracks of history. We don’t really know what happened to them but we get the occasional glimpse, for example, from a study in Sweden we know that a lot of old people moved into workhouses and a lot of the children became vagrants.

Men were more vulnerable than women overall globally, though there were regional variations. Pregnant women were particularly vulnerable and had miscarriages at frighteningly high numbers because, to fight the virus, the body took resources away from the womb and the growing foetus. Some of those babies survived and we know now there’s a lifelong effect called foetal programming. That generation was physically and cognitively slightly reduced. They were more likely to suffer from heart attacks and to go to prison – and came of age just in time to go and fight in the Second World War.

. . . .

In many Western countries, there was a turning away from science after the pandemic because people were disillusioned with it. From the 1920s, for example, in America, alternative medicine took off in a big way and spread around the world.

But at the same time, in countries that had not really embraced the scientific method, you see the opposite effect. So China becomes a little bit more scientific after the pandemic. There’s a move to better disease surveillance, better public health, more organized collection of healthcare data, because they saw that to prevent future pandemics they needed to turn towards science.

. . . .

The Spanish flu was democratic on one level. It could infect anyone: British Prime Minister David Lloyd George came down with the flu and Boris Johnson has had COVID-19 today. Nobody is, in theory, spared.

If you look at the population level though, there’s a very clear disparity and basically the poorest, the most vulnerable, the ones with the least good access to healthcare, the ones who work the longest hours, who live in the most crowded accommodation, and so on, are more at risk.

But in 1918, it was a time of eugenics-type thinking and it was perceived that those people who were more prone to the flu were constitutionally somehow inferior, that it was somehow their fault.

. . . .

The dates of the waves were dependent on where you were in the world. They came later in the Southern hemisphere, which meant Australia had the luxury of seeing this thing approach in space and time from the north, and took advantage of that to put in place maritime quarantine.

It managed to keep out the lethal second wave in October 1918, which is one of the rare exceptions of public health measures really working that year. But they lifted it too soon and the third wave of infection of early 1919 came into the country and killed 12,000 Australians. But it would have been much, much worse if they had not put the quarantine in place when they did.

Link to the rest at the World Economic Forum

15 thoughts on “How the Spanish flu changed the world”

  1. I find it interesting that almost anything I see written about the Spanish Flu says 500m were infected and 50m died. It feels as this is now folk law, when the real answer to both is “we don’t know”, and that no-one wants to admit our ignorance. Of course, estimating the number infected is particularly problematic as not only do we not know the infection rates but we also do not know the world population numbers (the OP implies 1.5b but I’ve seen estimates as high as 1.92b).

    For what it’s worth, a paper in the December 2018 American Journal of Epidemiology estimated the total to be about 17m deaths, but this is of course disputed. However, saying between 17m and 100m died doesn’t make your figures sound reliable.

    • If you’re talking about world-wide data on almost anything, it’s always a best-guess, Mike.

      Population statistics, mortality, etc., are collected in different manners and with varying degrees of accuracy on a country-by-country basis.

      First World statistics are usually regarded as the most accurate. Third World, not so much.

      Reliability can be effected by a huge number of variables, including who is collecting, what information is being collected, communications to all areas in a nation, efficiency of government departments processing the data, political considerations (consider, for example, The Great Leap Forward in China) and a bunch of other factors.

      In some cases, proxies may be used to infer data – Civil War cemeteries, court records, land transactions recorded, etc.

      If my recollection is correct, the Vietnam War Memorial in Washington, DC, included room for additional names to be added in the event that veterans died from war-related causes after the memorial was first built.

      If you consider that particular group of people, if a 70-year-old veteran of the Vietnam War who suffered from PTSD commits suicide, is that a war death or a death due to aging and depression or a death that is accelerated by the death of a spouse or other close relative or friend or a death caused by an increasingly dire financial situation?

      It’s quite possible that such a death could be included in several different cause-of-death reports. Sometimes, a physician treating such a patient who knows the patient well puts down a best-guess on the death certificate.

      There will always be a degree of inaccuracy in almost any data set involving a large number of people.

      • Very true, PG. I think we are seeing the same thing currently with Corvid-19 deaths where, in addition to the “normal” data collection problems there are basic disagreements as to whether a death should be classified as due to the coronavirus when other co-morbidities might better be blamed. In the UK a proportion of deaths in the elderly have been of people for whom the doctors had “do not resuscitate” instructions, which have tended to be interpreted as requiring limited treatment if infected. On the other hand, the restrictions imposed to fight the pandemic may themselves be causing non-Covid deaths which should possibly be included as due to the impact of the disease.

        • In a lot of places, any death involving respiratory sympthoms gets automatically tallied to covid without any effort to determine if another cause might be involved. Early in the year it was somewhat justifiable but we are entering prime Influenza season. Which by itself can be as deadly as covid and in similar ways.
          I have yet to see any reports on which version of the flu is prevalent this year or how much of an issue it might be but the last thing we need is a a problematic flu outbreak atop covid, incoming vaccines or not.

          • If people actually acted on all the advice re avoiding covid-19 (hand washing, social distancing, etc.), if the uptake of the flu vaccine is good, and if the updates made to the vaccines for the 2020-2021 northern hemisphere flu season prove appropriate, then both our countries could have one of the best flu seasons for many years (lots of “ifs” here, but Australia seems to have had a mild flu season in their last winter, so maybe not an unreasonable hope).

            In the UK the main figures for covid deaths are for “deaths within 28 days of positive test” which both misses some deaths (untested cases and those taking “too long” to die) and includes others which probably had different causes. At least the 28 day limit ended the situation where you could never be considered to have recovered from covid. There is another data set – running in arrear – that picks up any case where covid is mentioned on the death certificate, which in practice is probably close to your “any death involving respiratory sympthoms”.

  2. Will we ever know how 1918-19 compares to 2020? I doubt it. We can make guesses and compare the aftermaths, but answers from history are hazily seen through the lens of the present, which is clouded by the day’s emotions.

    That said, I like the Economist’s metric: measure excess deaths. https://www.economist.com/graphic-detail/2020/07/15/tracking-covid-19-excess-deaths-across-countries

    Excess deaths measures one economic aspect of the effects of covid-19. Whether someone died directly from covid-19, a previous condition exacerbated by covid-19, or from lack of medical care because healthcare facilities are swamped makes little difference economically. They are all the result of covid-19. And death is bad for business. At least in the short term.

    For the 1918-19 flu pandemic, measuring excess deaths seems nearly impossible– the data sets are either non-existent or unverifiable. We’re in a better position for covid-19, but the numbers are complex and probably less easily interpreted than anyone would like. It will take the data specialists years to sort the correlations, causes, and effects.

      • On the other hand, doing nothing in the face of danger is also foolish. I’ve been happy with the response in my state, Washington. Although we were the first state affected by covid-19, our death rate has been relatively low. (34 per 100,000 compared to 111 in ND, 135 in LA, 124 in MI, similarly rural states.) I attribute this to a rational response to a clear danger.

        In retrospect, the first stage of lock down was too tight, but that was because the transmission of the virus was not understood. As understanding increased, and infection rates went down, the lock down was eased. It’s tightening again, but much more selectively as the disease is becoming more understood.

        We’re still in danger: the number of available hospital beds in the state is declining and infections are increasing. As promising as the vaccines are, we have several months before they come online, months in which the those hospital beds will be critical.

        Could the response have been better? Of course. But I would not call the response panic. It’s not like deadly epidemics are new. The world has dealt with several in the last few decades with some success and the current response was based on that experience. That’s rational to me.

        • The panic is in the coverage in the mainstream media.
          On the government side, as you said, the early overreaction was understandable…for a while. It dragged on well past the point when the spread was better understood. Probably because it is an election year and the press panic drove tbe CYA and blame game.

          The second and more important issue and the one swept under the rug by the media was the degradation of emergency supplies at both the national and state levels over the last decade, with both sides ending investment in the stockpiles because of the 2008 economic crisis, counting on the other side to carry the load. A classic “failure to communicate” that drove what used to be the best preparedness in the world in 2008 to one barely able to cope with the first wave.

          https://www.msn.com/en-us/news/us/governors-were-warned-of-a-pandemic-told-to-stockpile-why-didnt-they-do-more/ar-BB13narq

          This is one case that politicians’ tradition of kicking the can down the road came back to bite everyone.

          • I find the poor response in the U.S. humbling because the U.S., New Zealand, and Taiwan shared the same pandemic playbook, which was developed under George W. Bush.

            I took the trouble to compare their playbooks back in October. They are the same plan. New Zealand, Taiwan, and quite a few other countries based their plans on the U.S. plan. Both New Zealand and Taiwan have covid-19 under control. Their infection and death rates per million are low, orders of magnitude lower than the U.S.

            The difference: NZ and TW executed on the plan. The U.S. floundered. Taiwan and New Zealand are triumphs of the U.S. CDC. The U.S. is its failure.

            The 2019 Global Health Security Index https://www.ghsindex.org/ , a report produced by an international group of institutions, including Johns Hopkins Center for Health Security and The Economist magazine, ranked the U.S. number one in preparedness. So much for that. The UK was ranked second. In execution, both ended up near the bottom of the list.

            I marshaled more background in a post I wrote: https://vinemaple.net/studio/the-cdc-triumph/

            As someone once said, the best plan means nothing if it is not executed.

            • Also note one thing Taiwan and New Zealand share: they are small, low population islands, and isolated. (South Korea, effectively). Easy to control their borders.

              The US is none of the above (and border controls are politically contentious) and on top of it, the stockpiles that were to feed The Plan weren’t maintained. And the plan to develop and buy a massive stockpile of cheap respirators was killed in 2010.

              • Actually, Taiwan is one of the 20 most densely populated countries in the world. They also have extensive trade and travel with the Chinese mainland. They are heavily invested in mainland China and much of Taiwan’s manufacturing is done in China, the early epicenter of the epidemic. With a dense population and extensive travel with mainland China, they had their hands full in the beginning.

                Compare Taiwan’s performance with North Dakota. ND population density: 10 / sq mile. Taiwan: 1700 / sq mile. Taiwan death rate: 2.4 / 100,000. ND death rate: 111 / 100,000. Who had the harder battle and who did best? The governments that executed the CDC plan.

                NZ had it easier, about twice as dense as ND, but they still had only 39 cases 100,000 compared to ND’s 111. The U.S. as a whole did poorly, even though we wrote the plan.

                Mistakes were made by the governments of both U.S. parties, but mistakes, big deadly mistakes, were made. It remains to be seen how deadly as infection rates continue to increase and hospital beds continue to dwindle.

                • I wasn’t thinking density as much as totals.
                  New Zealand – 4.5M (Houston)
                  Taiwan – 20M (NYC metro)

                  Even South Korea at 50M is more manageable than California.

                  Density impacts spread, yes, but size magnifies the resource problem and tracking the infection chains.

                  It was always going to be harder in the best of situations and the leadership all over has hardly been the best or even close.

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